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Han S, Shin S, Kim O, Hong N. Characteristics Associated with Bone Loss after Spinal Cord Injury: Implications for Hip Region Vulnerability. Endocrinol Metab (Seoul) 2023; 38:578-587. [PMID: 37816499 PMCID: PMC10613772 DOI: 10.3803/enm.2023.1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGRUOUND In individuals with spinal cord injury (SCI), bone loss progresses rapidly to the area below the level of injury, leading to an increased risk of fracture. However, there are limited data regarding SCI-relevant characteristics for bone loss and the degree of bone loss in individuals with SCI compared with that in non-SCI community-dwelling adults. METHODS Data from men with SCI who underwent dual-energy X-ray absorptiometry at the National Rehabilitation Center (2008 to 2020) between 12 and 36 months after injury were collected and analyzed. Community-dwelling men were matched 1:1 for age, height, and weight as the control group, using data from the Korea National Health and Nutrition Examination Survey (KNHANES, 2008 to 2011). RESULTS A comparison of the SCI and the matched control group revealed significantly lower hip region T-scores in the SCI group, whereas the lumbar spine T-score did not differ between groups. Among the 113 men with SCI, the paraplegia group exhibited significantly higher Z-scores of the hip region than the tetraplegia group. Participants with motor-incomplete SCI showed relatively preserved Z-scores of the hip region compared to those of the lumbar region. Moreover, in participants with SCI, the percentage of skeletal muscle displayed a moderate positive correlation with femoral neck Z-scores. CONCLUSION Men with SCI exhibited significantly lower bone mineral density of the hip region than community-dwelling men. Paraplegia rather than tetraplegia, and motor incompleteness rather than motor completeness were protective factors in the hip region. Caution for loss of skeletal muscle mass or increased adiposity is also required.
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Affiliation(s)
- Sora Han
- Department of Rehabilitation Medicine, National Rehabilitation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sungjae Shin
- Division of Endocrinology, Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Onyoo Kim
- Department of Rehabilitation Medicine, National Rehabilitation Center, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Division of Endocrinology, Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Zleik N, Weaver F, Harmon RL, Le B, Radhakrishnan R, Jirau-Rosaly WD, Craven BC, Raiford M, Hill JN, Etingen B, Guihan M, Heggeness MH, Ray C, Carbone L. Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review. J Spinal Cord Med 2019; 42:735-759. [PMID: 29745791 PMCID: PMC6830234 DOI: 10.1080/10790268.2018.1469808] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.Study Design: Scoping review.Settings/Participants: Human adult subjects with a SCI/D.Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.
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Affiliation(s)
- Nour Zleik
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Frances Weaver
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Robert L. Harmon
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
| | - Brian Le
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | | | - Wanda D. Jirau-Rosaly
- Department of Medicine, Division of Geriatrics, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Mattie Raiford
- School of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Jennifer N. Hill
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Bella Etingen
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
| | - Marylou Guihan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
| | - Michael H. Heggeness
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Cara Ray
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois, USA
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, Illinois, USA
| | - Laura Carbone
- Charlie Norwood Veterans Administration Medical Center, Augusta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Morse LR, Biering-Soerensen F, Carbone LD, Cervinka T, Cirnigliaro CM, Johnston TE, Liu N, Troy KL, Weaver FM, Shuhart C, Craven BC. Bone Mineral Density Testing in Spinal Cord Injury: 2019 ISCD Official Position. J Clin Densitom 2019; 22:554-566. [PMID: 31501005 DOI: 10.1016/j.jocd.2019.07.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023]
Abstract
Spinal cord injury (SCI) causes rapid osteoporosis that is most severe below the level of injury. More than half of those with motor complete SCI will experience an osteoporotic fracture at some point following their injury, with most fractures occurring at the distal femur and proximal tibia. These fractures have devastating consequences, including delayed union or nonunion, cellulitis, skin breakdown, lower extremity amputation, and premature death. Maintaining skeletal integrity and preventing fractures is imperative following SCI to fully benefit from future advances in paralysis cure research and robotic-exoskeletons, brain computer interfaces and other evolving technologies. Clinical care has been previously limited by the lack of consensus derived guidelines or standards regarding dual-energy X-ray absorptiometry-based diagnosis of osteoporosis, fracture risk prediction, or monitoring response to therapies. The International Society of Clinical Densitometry convened a task force to establish Official Positions for bone density assessment by dual-energy X-ray absorptiometry in individuals with SCI of traumatic or nontraumatic etiology. This task force conducted a series of systematic reviews to guide the development of evidence-based position statements that were reviewed by an expert panel at the 2019 Position Development Conference in Kuala Lumpur, Malaysia. The resulting the International Society of Clinical Densitometry Official Positions are intended to inform clinical care and guide the diagnosis of osteoporosis as well as fracture risk management of osteoporosis following SCI.
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Affiliation(s)
- Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA.
| | - Fin Biering-Soerensen
- Clinic for Spinal Cord Injuries, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Laura D Carbone
- Charlie Norwood Veterans Affairs Medical Center, Augusta, GA, USA; Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tomas Cervinka
- Department of Physiotherapy and Rehabilitation, Faculty of Health and Welfare, Satakunta University of Applied Sciences, Pori, Finland
| | - Christopher M Cirnigliaro
- Department of Veterans Affairs Rehabilitation Research & Development Service National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
| | - Therese E Johnston
- Department of Physical Therapy, Jefferson College of Rehabilitation Sciences, Thomas Jefferson University, Philadelphia, PA
| | - Nan Liu
- Department of Rehabilitation Medicine and Osteoporosis and Metabolic Bone Disease Center, Peking University Third Hospital, Beijing, China
| | - Karen L Troy
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Frances M Weaver
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Health Services Research & Development, Department of Veterans Affairs, Hines VA Hospital, Hines, IL, USA; Department of Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, IL, USA
| | - Christopher Shuhart
- Swedish Bone Health and Osteoporosis Center, Swedish Medical Group, Seattle WA, USA
| | - Beverley C Craven
- Neural Engineering and Therapeutics Team, KITE Research Institute - University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario Canada
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Johnston TE, Marino RJ, Oleson CV, Schmidt-Read M, Leiby BE, Sendecki J, Singh H, Modlesky CM. Musculoskeletal Effects of 2 Functional Electrical Stimulation Cycling Paradigms Conducted at Different Cadences for People With Spinal Cord Injury: A Pilot Study. Arch Phys Med Rehabil 2015; 97:1413-1422. [PMID: 26705884 DOI: 10.1016/j.apmr.2015.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To compare the musculoskeletal effects of low cadence cycling with functional electrical stimulation (FES) with high cadence FES cycling for people with spinal cord injury (SCI). DESIGN Randomized pre-post design. SETTING Outpatient rehabilitation clinic. PARTICIPANTS Participants (N=17; 14 men, 3 women; age range, 22-67y) with C4-T6 motor complete chronic SCI were randomized to low cadence cycling (n=9) or high cadence cycling (n=8). INTERVENTIONS Low cadence cycling at 20 revolutions per minute (RPM) and high cadence cycling at 50 RPM 3 times per week for 6 months. Cycling torque (resistance per pedal rotation) increased if targeted cycling cadence was maintained. MAIN OUTCOME MEASURES Dual-energy x-ray absorptiometry was used to assess distal femur areal bone mineral density, magnetic resonance imaging was used to assess to assess trabecular bone microarchitecture and cortical bone macroarchitecture and thigh muscle volume, and biochemical markers were used to assess bone turnover. It was hypothesized that subjects using low cadence cycling would cycle with greater torque and therefore show greater musculoskeletal improvements than subjects using high cadence cycling. RESULTS A total of 15 participants completed the study. Low cadence cycling obtained a maximal average torque of 2.9±2.8Nm, and high cadence cycling obtained a maximal average torque of 0.8±0.2Nm. Low cadence cycling showed greater decreases in bone-specific alkaline phosphatase, indicating less bone formation (15.5% decrease for low cadence cycling, 10.7% increase for high cadence cycling). N-telopeptide decreased 34% following low cadence cycling, indicating decreased resorption. Both groups increased muscle volume (low cadence cycling by 19%, high cadence cycling by 10%). Low cadence cycling resulted in a nonsignificant 7% increase in apparent trabecular number (P=.08) and 6% decrease in apparent trabecular separation (P=.08) in the distal femur, whereas high cadence cycling resulted in a nonsignificant (P>.3) 2% decrease and 3% increase, respectively. CONCLUSIONS This study suggests that the greater torque achieved with low cadence cycling may result in improved bone health because of decreased bone turnover and improved trabecular bone microarchitecture. Longer-term outcome studies are warranted to identify the effect on fracture risk.
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Affiliation(s)
- Therese E Johnston
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, PA.
| | - Ralph J Marino
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Christina V Oleson
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Benjamin E Leiby
- Division of Biostatics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Jocelyn Sendecki
- Division of Biostatics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - Harshvardhan Singh
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
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Gifre L, Vidal J, Carrasco JL, Muxi A, Portell E, Monegal A, Guañabens N, Peris P. Risk factors for the development of osteoporosis after spinal cord injury. A 12-month follow-up study. Osteoporos Int 2015; 26:2273-80. [PMID: 25939310 DOI: 10.1007/s00198-015-3150-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/22/2015] [Indexed: 12/14/2022]
Abstract
UNLABELLED Spinal cord injury (SCI) has been associated with a marked bone loss after injury and a consequent increased risk of osteoporosis. The evaluation of bone mineral density shortly after SCI is a simple and effective method for predicting the development of osteoporosis during the first year after SCI. INTRODUCTION Spinal cord injury (SCI) has been associated with a marked bone loss after injury and a consequent increased risk of osteoporosis and fractures. The aim of this study was to analyze the factors associated with osteoporosis development short-term after SCI. METHODS We included patients with complete recent SCI (<6 months) evaluating bone turnover markers (P1NP, bone ALP, and sCTx), 25-OH-vitamin D (25OHD) levels, and lumbar and femoral BMD (Lunar, Prodigy) at baseline, 6 and 12 months after SCI. The risk factors for osteoporosis analyzed included the following: age, gender, BMI, toxic habits, bone turnover markers, 25OHD levels, lumbar and femoral BMD, level, severity and type of SCI, and days-since-injury. Osteoporosis was defined according to WHO criteria. RESULTS Thirty-five patients aged 35 ± 16 years were included, and 52 % developed osteoporosis during the 12-month follow-up. These latter patients had lower BMD values at femur and lumbar spine and higher bone turnover markers at baseline. On multivariate analysis, the principal factors related to osteoporosis development were as follows: total femur BMD <1 g/cm(2) (RR, 3.61; 95 % CI 1.30-10.06, p = 0.002) and lumbar BMD <1.2 g/cm(2) at baseline (0.97 probability of osteoporosis with both parameters under these values). Increased risk for osteoporosis was also associated with increased baseline values of bone ALP (>14 ng/mL) (RR 2.40; 95 % CI 1.10-5.23, p = 0.041) and P1NP (>140 ng/mL) (RR 3.08; 95 % CI 1.10-8.57, p = 0.017). CONCLUSIONS The evaluation of BMD at the lumbar spine and femur short-term after SCI is a simple, effective method for predicting the development of osteoporosis during the first year after SCI. Our results also indicate the need to evaluate and treat these patients shortly after injury.
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Affiliation(s)
- L Gifre
- Metabolic Bone Diseases Unit, Service of Rheumatology, Hospital Clinic of Barcelona, Villarroel 170, 08036, Barcelona, Spain,
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Severe Spinal Cord Injury Causes Immediate Multi-cellular Dysfunction at the Chondro-Osseous Junction. Transl Stroke Res 2013; 2:643-50. [PMID: 22368723 DOI: 10.1007/s12975-011-0118-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Spinal cord injury is associated with rapid bone loss and arrested long bone growth due to mechanisms that are poorly understood. In this study, we sought to determine the effects of severe T10 contusion spinal cord injury on the sublesional bone microenvironment in adolescent rats. A severe lower thoracic (vertebral T10) spinal cord injury was generated by weight drop (10 g×50 mm). Severely injured and body weight-matched uninjured male Sprague-Dawley rats were studied. At 3 and 5 days post-injury, we performed histological analysis of the distal femoral metaphysis, TUNEL assay, immunohistochemistry, real-time PCR, and western blot analysis compared to uninjured controls. We observed severe hindlimb functional deficits typical of this model. We detected uncoupled remodeling with increased osteoclast activity in the absence of osteoblast activity. We detected osteoblast, osteocyte, and chondrocyte apoptosis with suppressed osteoblast and chondrocyte proliferation and growth plate arrest due to spinal cord injury. We also detected altered gene expression in both whole bone extracts and bone marrow monocytes following spinal cord injury. We conclude that spinal cord injury results in altered gene expression of key regulators of osteoblast and chondrocyte activity. This leads to premature cellular apoptosis, suppressed cellular proliferation, growth plate arrest, and uncoupled bone remodeling in sublesional bone with unopposed osteoclastic resorption.
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7
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Physical activity benefits bone density and bone-related hormones in adult men with cervical spinal cord injury. Eur J Appl Physiol 2012; 112:3179-86. [DOI: 10.1007/s00421-011-2303-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/26/2011] [Indexed: 10/14/2022]
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Maïmoun L, Fattal C, Sultan C. Bone remodeling and calcium homeostasis in patients with spinal cord injury: a review. Metabolism 2011; 60:1655-63. [PMID: 21632079 DOI: 10.1016/j.metabol.2011.04.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 04/13/2011] [Accepted: 04/16/2011] [Indexed: 01/27/2023]
Abstract
Patients with spinal cord injury exhibit early and acute bone loss with the major functional consequence being a high incidence of pathological fractures. The bone status of these patients is generally investigated by dual-energy x-ray absorptiometry, but this technique does not reveal the pathophysiological mechanism underlying the bone loss. Bone cell activity can be indirectly evaluated by noninvasive techniques, including measurement of specific biochemical markers of bone formation (such as osteocalcin or bone-alkaline phosphatase) and resorption (such as procollagen type I N- or C-terminal propeptide). The bone loss in spinal cord injury is clearly due to an uncoupling of bone remodeling in favor of bone resorption, which starts just after the injury and peaks at about 1 to 4 months. Beyond 6 months, bone resorption activity decreases progressively but remains elevated for many years after injury. Conversely, bone formation is less affected. Antiresorptive treatment induces an early and acute reduction in bone resorption markers. Level of injury and health-related complications do not seem to be implicated in the intensity of bone resorption. During the acute phase, the hypercalcemic status is associated with the suppression of parathyroid hormone and vitamin D metabolites. The high sensitivity of these markers after treatment suggests that they can be used for monitoring treatment efficacy and patient compliance. The concomitant use of bone markers and dual-energy x-ray absorptiometry may improve the physician's ability to detect patients at risk of severe bone loss and subsequent fractures.
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Affiliation(s)
- Laurent Maïmoun
- Département d'Hormonologie, Hôpital Lapeyronie, CHU Montpellier and UMI, 34295 Montpellier, France.
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Smith É, Carroll Á. Bone mineral density in adults disabled through acquired neurological conditions: a review. J Clin Densitom 2011; 14:85-94. [PMID: 21474350 DOI: 10.1016/j.jocd.2010.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 12/12/2010] [Accepted: 12/13/2010] [Indexed: 01/26/2023]
Abstract
This article is a review of the changes in bone mineral density (BMD), which occur in a number of acquired neurological conditions resulting in disability. For each of spinal cord injury, stroke, multiple sclerosis, Parkinson's disease, and traumatic brain injury, the following aspects are discussed, where information is available: prevalence of low BMD according to World Health Organization diagnostic categories and recommended diagnostic method, prevalence based on other diagnostic tools, comparison of BMD with a control population, rate of decline of BMD following onset of the neurological condition, factors influencing decline; mechanism of bone loss, and fracture rates. The common risk factors of immobilization and vitamin D deficiency would appear to cross all disability groups, with the most rapid phase of bone loss occurring in the acute and subacute phases of each condition.
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Affiliation(s)
- Éimear Smith
- National Rehabilitation Hospital, Dún Laoghaire, Co. Dublin, Ireland.
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10
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Intensive electrical stimulation attenuates femoral bone loss in acute spinal cord injury. PM R 2011; 2:1080-7. [PMID: 21145519 DOI: 10.1016/j.pmrj.2010.08.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 07/31/2010] [Accepted: 08/08/2010] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine whether intensive electrical stimulation (ES) can reduce femoral bone mineral density (BMD) loss in acute spinal cord injury (SCI). DESIGN Randomized controlled trial. SETTING Inpatient rehabilitation hospital. PARTICIPANTS Twenty-six subjects with C4 to T12 American Spinal Injury Association Impairment Scale A or B SCI less than 12 weeks postinjury. METHODS The control group received usual rehabilitative care and the intervention group received usual care plus 1 hour of ES over the quadriceps 5 days per week for 6 weeks. MAIN OUTCOME MEASUREMENTS Outcome measurements were collected at baseline, postintervention (interim), and 3 months postinjury (follow-up), and included dual energy x-ray absorptiometry, serum osteocalcin (OC), and urinary N-telopeptide (NTx). RESULTS In the control group, there was increasing BMD loss with distance from the spine (lumbar -1.88%, hip -12.25%, distal femur -15.15%, proximal tibia -17.40%). This trend was attenuated over the distal femur in the ES group (lumbar -1.29%, hip -14.45%, distal femur -7.40%, proximal tibia -12.31%). NTx increased over the 3 assessments in controls ([mean ± standard deviation] 115.00 ± 34.10, 154.86 ± 70.41, and 171.33 ± 75.8 nmol/mmol creatinine) compared with the ES group (160.56 ± 140.06, 216.71 ± 128.40, and 154.67 ± 69.12 nmol/mmol creatinine)-all of which were elevated compared with the reference range, and the differences between the 2 groups were not significant. Osteocalcin levels markedly decreased in the control group (12.90 ± 7.30, 24.00 ± 4.29, and 6.40 ± 7.28 μg/L) to subnormal levels, and remained stable and in the normal range in the ES group (13.80 ± 7.64, 11.86 ± 6.77, and 14.80 ± 12.91 μg/L), although differences between the groups were not significant. CONCLUSIONS Lower extremity BMD loss increases with distance from the spine. An intensive lower extremity ES program may attenuate BMD loss locally after acute motor complete SCI, although it is unknown whether these benefits are maintained in the long term.
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Osteoporosis in Persons With Spinal Cord Injury: The Need for a Targeted Therapeutic Education. Arch Phys Med Rehabil 2011; 92:59-67. [DOI: 10.1016/j.apmr.2010.09.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 09/06/2010] [Accepted: 09/08/2010] [Indexed: 11/22/2022]
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12
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An evidence-based review of aging of the body systems following spinal cord injury. Spinal Cord 2010; 49:684-701. [PMID: 21151191 DOI: 10.1038/sc.2010.178] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To systematically review evidence on aging of the body systems after spinal cord injury (SCI). SETTING Toronto, Ontario and Vancouver, British Columbia, Canada. METHODS Electronic databases (MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO), were searched for studies published between 1980 and 2009. The search was augmented by reviewing the reference lists of relevant papers. Non-intervention studies that were longitudinal or cross-sectional with able-bodied controls that were at minimum matched on chronological age were included for review. Levels of evidence were assigned to the study design using a modified Sackett scale. RESULTS Of the 74 studies selected for inclusion, 16 were longitudinal in design. The hypothesis that SCI represents a model for premature aging is supported by a large proportion of level 5 evidence for the cardiovascular and endocrine systems, level 2, 4 and 5 evidence for the musculoskeletal system, and limited level 5 evidence for the immune system. Only a few level 4 and 5 studies for the respiratory system were found. The evidence on the genitourinary system, gastrointestinal system, and for skin and subcutaneous tissues provide level 4 and 5 evidence that premature aging may not be occurring. The evidence on the nervous system does not provide evidence of premature aging as a result of SCI. CONCLUSIONS Premature aging appears to occur in some systems after SCI. Additional longitudinal studies are required to confirm these findings.
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Bauman WA, Kirshblum S, Cirnigliaro C, Forrest GF, Spungen AM. Underestimation of bone loss of the spine with posterior-anterior dual-energy X-ray absorptiometry in patients with spinal cord injury. J Spinal Cord Med 2010; 33:214-20. [PMID: 20737794 PMCID: PMC2920114 DOI: 10.1080/10790268.2010.11689698] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Bone mineral density (BMD) of the lumbar spine (L-spine) has been reported to be normal by routine posterior-anterior (PA) bone density imaging in patients with chronic spinal cord injury (SCI). OBJECTIVE To determine BMD of the L-spine by PA and lateral (LAT) dual-energy radiographic absorptiometry (DXA) in patients with chronic SCI. DESIGN Prospective study. SETTING Veterans Affairs Medical Center and a private rehabilitation facility. METHODS Measurements of the PA and LAT L-spine and hip were performed in 15 patients with SCI: 9 with tetraplegia and 6 with paraplegia. The DXA (GE Lunar Advance DXA) images were obtained using standard software. Results are reported as mean +/- SD. RESULTS The mean age was 35 +/- 15 years (range = 20-62 years), and the duration of injury was 57 +/- 74 months (range = 3-240 months). T- and Z-scores were lower for the LAT L-spine than those for PA L-spine (T-scores L2: -0.7 +/- 1.2 vs. 0.0 +/- 1.4, P < 0.01; L3: -0.9 +/- 1.6 vs. 0.3 +/- 1.3, P < 0.002; L2-L3: -0.8 +/- 1.3 vs. 0.2 1.3 vs. 0.2 +/- P < 0.001; Z-scores Z-0.3 +/- 1.1 vs. 0.2 +/- 1.2, P < 0.05; L3: -0.6 +/- 1.3 vs. 0.5 +/- 1.3, P < 0.01; L2-L3: -0.4 +/- 1.1 vs. 0.4 +/- 1.2, P < 0.005). The T- and Z-scores for the total hip (-1.1 +/- 1.0 and -1.0 +/- 1.0, respectively) and L2-L3 LAT L-spine demonstrated remarkable similarity, whereas the L2-L3 PA L-spine scores were not reduced. Bone mineral density of the LAT L-spine, but not the PA L-spine, was significantly reduced with increasing duration of injury. CONCLUSIONS Individuals with SCI may have bone loss of the L-spine that is evident on LAT DXA that may be misdiagnosed by PA DXA, underestimating the potential risk of fracture.
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Affiliation(s)
- William A Bauman
- Veterans Affairs Rehabilitation Research and Development Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Affairs Medical Center, Bronx, New York 10468, USA.
| | - Steven Kirshblum
- Kessler Institute of Rehabilitation, West Orange, New Jersey
,Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
,Kessler Foundation Research Center, West Orange, New Jersey
| | - Christopher Cirnigliaro
- Veterans Affairs Rehabilitation Research and Development Center of Excellence for the Medical Consequences of Spinal Cord Injury, Bronx, New York
,Medical, Spinal Cord Injury and Research Services, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Gail F Forrest
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey
,Kessler Foundation Research Center, West Orange, New Jersey
| | - Ann M Spungen
- Veterans Affairs Rehabilitation Research and Development Center of Excellence for the Medical Consequences of Spinal Cord Injury, Bronx, New York
,Medical, Spinal Cord Injury and Research Services, James J. Peters Veterans Affairs Medical Center, Bronx, New York
,Departments of Medicine and Rehabilitation Medicine, Mount Sinai Medical Center, New York, New York
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Sublesional spinal vertebral bone mineral density correlates with neurological level and body mass index in individuals with chronic complete spinal cord injuries. Spine (Phila Pa 1976) 2010; 35:958-62. [PMID: 20228706 DOI: 10.1097/brs.0b013e3181bc9dc9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A cross-sectional study. OBJECTIVE Our aim was to find out the factors influencing the bone mineral density (BMD) change of sublesional spinal vertebrae in spinal cord injury (SCI) individuals. SUMMARY OF BACKGROUND DATA In individuals with SCI, the BMD of sublesional extremities dramatically decreases to fracture threshold because of unloading. In contrast, the BMD of sublesional spinal vertebrae is reported to be preserved. The etiology of the discrepancy is unknown. METHODS This study was performed in a university tertiary referral medical center. A total of 62 men with traumatic and neurologically complete SCI attending a special SCI clinic attached to the medical center from 2000 to 2003. Participants were prescreened using lumbosacral roentgenography to rule out heterotopic ossification and early-onset spinal degeneration. The BMD was then evaluated with dual energy radiograph absorptiometry at the thoracic spine and lumbar spine, using anteroposterior and lateral scout images. RESULTS The mean age was 27.3 +/- 8.3 years and mean injury duration was 11.7 +/- 6.8 years. Lumbar spine BMD did not increase or decrease significantly after SCI. Lumbar spine BMD correlated significantly with body mass index. Thoracic and lumbar spine BMDs were significantly higher if the injury level was below T6. There were no correlations with postinjury duration, age of the subject, or level of physical activity. CONCLUSION In men with chronic complete SCI, the long-term sublesional spinal vertebrae BMDs are significantly lower if injury levels are at T6 or above, suggesting the role of neurologic control on bone metabolism.
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Dual-energy X-ray absorptiometry overestimates bone mineral density of the lumbar spine in persons with spinal cord injury. Spinal Cord 2009; 47:628-33. [PMID: 19153590 DOI: 10.1038/sc.2008.169] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bone mineral density (BMD) of the lumbar spine (L-spine) has been reported to be normal or increased in persons with chronic spinal cord injury (SCI). OBJECTIVE To determine BMD of the L-spine by dual-energy X-ray absorptiometry (DXA) and quantitative computerized tomography (qCT) in men with chronic SCI compared with able-bodied controls. DESIGN Cross-sectional, comparative study. SETTING Clinical research unit, Veterans Affairs Medical Center, Bronx, NY, USA and Kessler Institute of Rehabilitation, West Orange, NJ, USA. METHODS Measurements of the L-spine were made in 20 men with SCI and compared with 15 able-bodied controls. The DXA images were acquired on a GE Lunar DPX-IQ. The qCT images of the L-spine were acquired on a Picker Q series computerized tomographic scanner. RESULTS The mean ages for the SCI and control groups were 44+/-13 vs 42+/-9 years, and the duration of injury of the group with SCI was 14+/-11 years. There were no significant differences between the SCI and control groups for L-spine DXA BMD (1.391+/-0.210 vs 1.315+/-0.178 g/m(2)) or for L-spine DXA T-score (1.471+/-1.794 vs 0.782+/-1.481). L-spine qCT BMD was significantly lower in the SCI compared with the control group (1.296+/-0.416 vs 1.572+/-0.382 g/m(2), P=0.05); the T-score approached significance (-1.838+/-1.366 vs -0.963+/-1.227, P=0.059). Subjects with moderate degenerative joint disease (DJD) had significantly higher T-scores by DXA than those without or with mild DJD. CONCLUSION Individuals with SCI who have moderate to severe DJD may have bone loss of the L-spine that may be underestimated by DXA, reducing awareness of the risk of fracture.
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Barriers to providing dual energy x-ray absorptiometry services to individuals with spinal cord injury. Am J Phys Med Rehabil 2009; 88:57-60. [PMID: 18824888 DOI: 10.1097/phm.0b013e31818a5f87] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To assess barriers to bone mineral density testing in individuals with chronic spinal cord injury, a cross-sectional study of 20 individuals with spinal cord injury was conducted with assessment of physical and logistical barriers to dual energy x-ray absorptiometry scanning. We identified several barriers, including scanner design and configuration in the scanning room that limited accessibility, increased typical scanning time, and made additional staff necessary. For dual energy x-ray absorptiometry to become a routine component of ongoing care in spinal cord injury medicine, we recommend the following changes: (1) install ceiling-mounted hydraulic lifts and grab bars to facilitate transfers in the scanning room; (2) increase staffing during scans; (3) increase time allotment for scans; (4) install the scanner in an adequately-sized room; and (5) partner with administrators and staff to raise awareness of access issues faced by individuals with spinal cord injury.
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Effect of weight-bearing activities on bone mineral density in spinal cord injured patients during the period of the first two years. Spinal Cord 2008; 46:727-32. [PMID: 18443599 DOI: 10.1038/sc.2008.36] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Prospective study on patients with spinal cord injuries. OBJECTIVES To evaluate the loss of bone mineral density (BMD) in various body regions of patients with spinal cord injury (SCI) and its dependence on weight bearing activities during 2 years post injury. METHODS BMD of the whole body was measured in patients with SCI. Baseline measurement was performed in 6-16 weeks after SCI, the second and the third-respectively 12 and 24 months after injury. Fifty-four subjects were selected and divided into two groups: standing and non-standing. From these groups 27 pairs were made according to gender, age and height. RESULTS There was found to be a well-marked decrease in BMD values for lower extremities, but there was no significant difference between paraplegic and tetraplegic patients 1 and 2 year after injury. Leg BMD reduced by 19.62% (95% CI, 17-22%) in the standing group and by 24% (95% CI, 21-27%) in non-standing group during the first year. Two years after SCI patients in standing group had significantly higher leg BMD-1.018 g/cm(2) (95% CI, 0.971-1.055 g/cm(2)) than in the non-standing group-0.91 g/cm(2) (95% CI, 0.872-0.958 g/cm(2)) (P<or=0.0001). CONCLUSION SCI patients who performed daily standing >or=1 h and not less than 5 days per week, had significantly higher BMD in the lower extremities after 2 years in comparison to those patients who did not perform standing.
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Garland DE, Adkins RH, Stewart CA. Five-year longitudinal bone evaluations in individuals with chronic complete spinal cord injury. J Spinal Cord Med 2008; 31:543-50. [PMID: 19086712 PMCID: PMC2607127 DOI: 10.1080/10790268.2008.11753650] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/OBJECTIVES Knowledge of spinal cord injury (SCI) bone changes has been derived primarily through cross-sectional studies, many of which are controvertible. Longitudinal studies are sparse, and long-term longitudinal chronic studies are unavailable. The objective of this study was to provide a clearer perception of chronic longitudinal bone variations in people with complete SCI. METHODS Bone status of 31 individuals with chronic, complete SCI was assessed twice using dual-energy xray absorptiometry at an average interval of 5.06 +/- 0.9 years. Because the sample of women was small (4), the primary analyses of change and comparisons of those with paraplegia vs tetraplegia were confined to the male participants. RESULTS Spine Z-scores showed a significant increase (P < 0.0001). The average Z-scores, initial and followup, were within the normal range. Hip Z-scores also showed a significant increase (P < 0.0001), and hip bone mineral density (BMD) increased in 48% of the participants. Knee BMD and lower extremity total bone mineral showed significant decreases (P < 0.003 and P < 0.02, respectively), but increases were seen in 33% and 26% at the respective sites. Individuals with tetraplegia had significantly lower values across all regions (P < 0.0001), and changes were significantly different compared with paraplegia (P < 0.0001). Bone values and changes in men vs women, despite the small sample of women, showed highly significant differences (P < 0.003-0.002). CONCLUSION Chronic effects of complete SCI do not exclusively result in continued loss of BMD or a static state of lowered BMD; gain in BMD may occur. The nature and magnitude of the effects of complete SCI on BMD vary by site, with sex and level of injury, which has implications for treatment and its assessment.
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Affiliation(s)
- Douglas E Garland
- 1SCI Project, Los Amigos Research and Education Institute, Downey, California,2University of Southern California, Los Angeles, California
| | - Rodney H Adkins
- 1SCI Project, Los Amigos Research and Education Institute, Downey, California,3Rehabilitation Research and Training Center on Aging with a Disability, Rancho Los Amigos Research and Education Institute, Downey, California
| | - Charles A Stewart
- 1SCI Project, Los Amigos Research and Education Institute, Downey, California,4University of California, Los Angeles School of Medicine, Los Angeles, California,5Department of Medical Imaging, Rancho Los Amigos Research and Education Institute, Downey, California
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Jiang SD, Jiang LS, Dai LY. Effects of spinal cord injury on osteoblastogenesis, osteoclastogenesis and gene expression profiling in osteoblasts in young rats. Osteoporos Int 2007; 18:339-49. [PMID: 17036173 DOI: 10.1007/s00198-006-0229-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 08/29/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Spinal cord injury (SCI) causes a significant amount of bone loss in the sublesional area in animals and humans, and this type of bone loss is different from other forms of osteoporosis such as disuse osteoporosis and postmenopausal osteoporosis. However, no data is available on the cellular and molecular changes of osteoblastogenesis and osteoclastogenesis during SCI-induced bone loss. METHODS SCI and SHAM rats were used in this study to investigate osteoblastogenesis and osteoclastogenesis in bone-marrow culture. We also measured bone mass and bone histomorphometry, as well as the expression of alkaline phosphatase (ALP), core binding factor alpha1 (Cbfa-1), osterix, receptor activator of NF-kappaB ligand (RANKL) and osteoprotegerin (OPG) in osteoblast-like cells in bone-marrow culture obtained from SCI and SHAM rats. RESULTS Bone mineral density (BMD) measurement showed serious bone loss in the tibial ephiphyses and metaphyses of SCI rats compared with SHAM rats. In addition, bone histomorphometry analysis of the tibial metaphyses of SCI rats demonstrated that bone microarchitecture in SCI rats deteriorated further than in SHAM rats, and increased eroded surfaces and bone formation rates were observed in SCI rats. The number of osteoclasts that developed from bone marrow of SCI rats at equal density was significantly increased compared with SHAM rats, and the area of the resorption pits formed in the bone marrow culture from SCI rats was significantly greater than SHAM rats, whereas the number of CFU-F and CFU-OB was similar in both groups. RANKL mRNA and protein levels in osteoblast-like cells in culture obtained from SCI rats were significantly higher than those from the SHAM rats, whereas OPG levels decreased slightly. The ratios of RANKL to OPG expression in SCI rats were significantly higher than those in SHAM rats. However, osteogenic gene profiling of Cbfa-1, ALP and osterix in SCI rats remained similar with SHAM rats. CONCLUSION These changes favor increased osteoclast activity over osteoblast activity, and may explain, in part, the imbalance in bone formation and resorption following SCI.
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Affiliation(s)
- S-D Jiang
- Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai, China.
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20
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Giangregorio LM, Hicks AL, Webber CE, Phillips SM, Craven BC, Bugaresti JM, McCartney N. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord 2006; 43:649-57. [PMID: 15968302 DOI: 10.1038/sj.sc.3101774] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
DESIGN Longitudinal prospective case series. OBJECTIVE To evaluate the impact of early introduction post-spinal cord injury (SCI) of twice-weekly body-weight supported treadmill training (BWSTT) on muscle and bone. SETTING Centre for Health Promotion and Rehabilitation, McMaster University, Canada. METHODS Five individuals who had sustained traumatic SCI within 2-6 months participated in the study. Bone mineral densities (BMD) of proximal femur, distal femur, proximal tibia and lumbar spine were measured before and after training, as well as muscle cross-sectional area (CSA), BMD and bone geometry at mid-femur and proximal tibia. Serum osteocalcin and urinary deoxypyridinoline were measured at baseline, and after 24 and 48 sessions of training. RESULTS All participants experienced increased muscle CSAs, ranging from 3.8 to 56.9%. Reductions in BMD were evident in all participants at almost all lower limb sites after training, ranging in magnitude from -1.2 to -26.7%. Lumbar spine BMD changes ranged from 0.2 to -7.4%. No consistent changes were observed in bone geometry. BWSTT did not alter the expected pattern of change in bone biochemical markers over time. The individual with the greatest improvement in ambulatory ability demonstrated the smallest reduction in lower limb BMD. Conversely, the individual who completed the fewest BWSTT sessions demonstrated the greatest reductions in BMD. CONCLUSIONS Twice-weekly BWSTT appeared to partially reverse muscle atrophy after SCI, but did not prevent bone loss. Larger, controlled trials should evaluate whether relative preservation of bone loss occurs with regular BWSTT following acute SCI. SPONSORSHIP Ontario Neurotrauma Foundation.
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Affiliation(s)
- L M Giangregorio
- Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, Ontario, Canada
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Abstract
Osteoporosis is a known consequence of spinal cord injury (SCI) and occurs in almost every SCI patient. It manifests itself as an increase in the incidence of lower extremity fractures. The pattern of bone loss seen in SCI patients is different from that usually encountered with endocrine disorders and disuse osteoporosis. In general, there is no demineralization in supralesional areas following SCI. Several factors appear to have a major influence on bone mass in SCI individuals, such as the degree of the injury, muscle spasticity, age, sex and duration after injury. At the lumbar spine, bone demineralization remains relatively low compared to that of the long bones in the sublesional area. A new steady state level between bone resorption and formation is reestablished about 2 years after SCI. SCI may not only cause bone loss, but also alter bone structure and microstructure. Trabecular bone is more affected than cortical bone in the SCI population. Numerous clinical series have reported a high incidence ranging from 1 to 34% of lower extremity fractures in SCI patients. The pathogenesis of osteoporosis after SCI remains complex and perplexing. Disuse may play an important role in the pathogenesis of osteoporosis, but neural factors also appear to be important. SCI also leads to impaired calcium and phosphate metabolism and the parathyroid hormone (PTH)-vitamin D axis. Pharmacologic intervention for osteoporosis after SCI includes calcium, phosphate, vitamin D, calcitonin and biphosphonates. However, the concomitant prescription of bone-active drugs for the prevention and treatment of osteoporosis remains low, despite the availability of effective therapies. Functional stimulated exercises may contribute to the prevention of bone loss to some extent. In addition, many unanswered questions remain about the pathogenesis of osteoporosis and its clinical management.
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Affiliation(s)
- Sheng-Dan Jiang
- Department of Orthopedic Surgery, Xinhua Hospital of the Shanghai Second Medical University, 1665 Kongjiang Road, 200092, Shanghai, China
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Johnston TE, Betz RR, Smith BT, Benda BJ, Mulcahey MJ, Davis R, Houdayer TP, Pontari MA, Barriskill A, Creasey GH. Implantable FES system for upright mobility and bladder and bowel function for individuals with spinal cord injury. Spinal Cord 2006; 43:713-23. [PMID: 16010275 DOI: 10.1038/sj.sc.3101797] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Postintervention. OBJECTIVES To determine the effectiveness of the Praxis multifunctional implantable functional electrical stimulation (FES) system (Neopraxis Pty. Ltd, Lane Cove, NSW, Australia) to provide standing and stepping ability and bladder and bowel management for individuals with motor complete thoracic level spinal cord injuries (SCI). SETTING Pediatric orthopedic hospital specializing in SCI. SUBJECTS Three males, ages 17 and 21 years, with motor-complete thoracic level SCI and intact lower motor neurons to the muscles targeted for stimulation. METHODS Each subject was successfully implanted with the Praxis FES system. All three subjects received electrodes for upright mobility and the first two subjects received additional electrodes for stimulated bladder and bowel management. Following training, subjects were evaluated in their ability to use FES for nine mobility activities. Acute and chronic experiments of the effect of stimulation on bowel and bladder function were also performed. RESULTS All three subjects could independently stand up from the wheelchair and could walk at least 6 m using a swing through gait pattern. Two subjects were able to independently perform swing through gait for 6 min and one subject was able to independently ascend and descend stairs. Suppression of reflex bladder contractions by neuromodulation (subject 1) and stimulated contractions of the rectum (subject 2) were observed in acute experiments. When stimulation was applied over the course of several weeks, a positive effect on bowel function was measured. Stimulated bladder contractions were not achieved. CONCLUSION The feasibility of using the Praxis FES system for upright mobility and aiding aspects of bladder and bowel function was demonstrated with three subjects with thoracic level SCI.
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Affiliation(s)
- T E Johnston
- Shriners Hospitals for Children, 3551 North Broad St, Philadelphia, PA, USA
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Giangregorio L, McCartney N. Bone loss and muscle atrophy in spinal cord injury: epidemiology, fracture prediction, and rehabilitation strategies. J Spinal Cord Med 2006; 29:489-500. [PMID: 17274487 PMCID: PMC1949032 DOI: 10.1080/10790268.2006.11753898] [Citation(s) in RCA: 227] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Individuals with spinal cord injury (SCI) often experience bone loss and muscle atrophy. Muscle atrophy can result in reduced metabolic rate and increase the risk of metabolic disorders. Sublesional osteoporosis predisposes individuals with SCI to an increased risk of low-trauma fracture. Fractures in people with SCI have been reported during transfers from bed to chair, and while being turned in bed. The bone loss and muscle atrophy that occur after SCI are substantial and may be influenced by factors such as completeness of injury or time postinjury. A number of interventions, including standing, electrically stimulated cycling or resistance training, and walking exercises have been explored with the aim of reducing bone loss and/or increasing bone mass and muscle mass in individuals with SCI. Exercise with electrical stimulation appears to increase muscle mass and/or prevent atrophy, but studies investigating its effect on bone are conflicting. Several methodological limitations in exercise studies with individuals with SCI to date limit our ability to confirm the utility of exercise for improving skeletal status. The impact of standing or walking exercises on muscle and bone has not been well established. Future research should carefully consider the study design, skeletal measurement sites, and the measurement techniques used in order to facilitate sound conclusions.
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Affiliation(s)
- Lora Giangregorio
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.
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de Bruin ED, Vanwanseele B, Dambacher MA, Dietz V, Stüssi E. Long-term changes in the tibia and radius bone mineral density following spinal cord injury. Spinal Cord 2005; 43:96-101. [PMID: 15534621 DOI: 10.1038/sj.sc.3101685] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
DESIGN A prospective inception cohort study with an observational analytic design in a spinal cord injury (SCI) centre hospital. OBJECTIVE To assess changes in trabecular and compact bone of the tibia and radius prospectively in subjects with SCI. SUBJECTS In total, 10 individuals with an acute SCI. METHODS Trabecular and compact bone density of the tibia and radius by peripheral quantitative computerised tomography. RESULTS Analysis of the individual gradients of the curve coefficient showed changes in trabecular bone between -0.19 and -2.46 and in cortical bone between +0.07 and -0.93 in the tibia within 34 months after the SCI. Both trabecular and cortical bone showed a group mean loss of 99 mg/cm(3). No changes were observed in the radius. CONCLUSION There is a major decrease in tibia mineral density over 3 years; however, no change is observed for the radius mineral content. Large interindividual differences existed in the patterns of loss in the tibia bone substance after SCI. These patterns indicate that there is no steady state of bone mineral density following 3 years of spinal cord injury.
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Affiliation(s)
- E D de Bruin
- Laboratory for Biomechanics, Swiss Federal Institute of Technology, Zürich, Switzerland
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Eser P, Frotzler A, Zehnder Y, Denoth J. Fracture threshold in the femur and tibia of people with spinal cord injury as determined by peripheral quantitative computed tomography. Arch Phys Med Rehabil 2005; 86:498-504. [PMID: 15759235 DOI: 10.1016/j.apmr.2004.09.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine bone traits of the femur and tibia with peripheral quantitative computed tomography (pQCT) that best distinguish between spinal cord injury (SCI) subjects with and without fractures. DESIGN Cross-sectional study. SETTING In- and outpatient paraplegic center in Switzerland. PARTICIPANTS Ninety-nine motor complete SCI subjects (duration of paralysis, 2 mo-49 y), 21 of whom had sustained fractures of the femur or tibia. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Subjects with SCI were questioned about the occurrence, location, and approximate date of fractures to their lower extremities. Trabecular and cortical bone mineral density (BMD), as well as bone geometric properties of distal epiphyses and midshafts of the femur and tibia, were measured by pQCT. RESULTS Trabecular BMD of the femur and tibia distal epiphyses was found to distinguish best subjects with fractures from those without. Fractures occurred in subjects with trabecular BMD of less than 114 mg/cm 3 and less than 72 mg/cm 3 for the femoral and tibial distal epiphysis, respectively (corresponding to 46% and 29% of mean values of an able-bodied reference group). Approximately 50% of the subjects with chronic SCI (defined as time postinjury >5 y for femur data and >7 y for tibia data) had trabecular BMD values above the fracture threshold in the femur and about one third above the fracture threshold in the tibia. CONCLUSIONS By using pQCT, it may be possible to identify subjects with SCI who are at risk of sustaining fractures of the femur and tibia through minor trauma.
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Affiliation(s)
- Prisca Eser
- Institute for Clinical Research, Swiss Paraplegic Centre, Nottwil, Switzerland.
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Moran de Brito CM, Battistella LR, Saito ET, Sakamoto H. Effect of alendronate on bone mineral density in spinal cord injury patients: a pilot study. Spinal Cord 2005; 43:341-8. [PMID: 15700052 DOI: 10.1038/sj.sc.3101725] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective, randomised controlled trial. OBJECTIVE To evaluate the effect of alendronate on bone mineral density in chronic spinal cord injury (SCI) patients. SETTING University-based rehabilitation centre in São Paulo, Brazil. METHODS A total of 19 chronic SCI patients were evaluated, divided into a control group and an experimental group. Control group patients received 1000 mg of calcium daily, and experimental group patients received 1000 mg of calcium plus 10 mg of alendronate daily. The study duration was 6 months. In all, 12 densitometric parameters were analysed using whole-body dual-energy X-ray absorptiometry at baseline and after 6 months. RESULTS The experimental group presented increases in nine densitometric parameters, although statistical significance was attained in only two of those parameters. In the control group, an increase was observed in only one parameter, whereas the remaining 11 presented either no alteration or a decrease. CONCLUSION The use of alendronate had a positive effect on bone mineral density in SCI patients and therefore represents a potential tool for prevention and treatment of osteoporosis in this population.
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Affiliation(s)
- C M Moran de Brito
- Department of Rehabilitation Medicine, University of São Paulo Hospital das Clínicas, São Paulo, Brazil
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Goktepe AS, Yilmaz B, Alaca R, Yazicioglu K, Mohur H, Gunduz S. Bone density loss after spinal cord injury: elite paraplegic basketball players vs. paraplegic sedentary persons. Am J Phys Med Rehabil 2004; 83:279-83. [PMID: 15024329 DOI: 10.1097/01.phm.0000118036.20170.6c] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the bone mineral density of elite paraplegic basketball players with the values obtained from their paraplegic sedentary counterparts. DESIGN A total of 17 male paraplegic basketball players and 17 male paraplegic sedentary persons were included in the study. Bone mineral densities of the distal third of radius of the dominant arm, L2-L4 spine, and trochanters, Ward's triangles, and the femoral necks of both hips were measured. RESULTS The densities of trochanters, Ward's triangles, and the femoral necks were found to be decreased in both groups, with no significant difference between them. The densities of lumbar and radial regions were found to be increased in both groups. Radial density was significantly higher in paraplegic basketball players than in paraplegic sedentary patients, whereas the groups were not significantly different for lumbar density. CONCLUSIONS Wheelchair basketball in spinal cord-injured patients was associated with greater bone density in distal radius compared with sedentary paraplegics. However, it was not associated with greater density below the injury level.
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Affiliation(s)
- A Salim Goktepe
- Department of Physiatry, Turkish Armed Forces Rehabilitation Center, Gulhane Military Medical Academy, Ankara, Turkey
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Eser P, Frotzler A, Zehnder Y, Wick L, Knecht H, Denoth J, Schiessl H. Relationship between the duration of paralysis and bone structure: a pQCT study of spinal cord injured individuals. Bone 2004; 34:869-80. [PMID: 15121019 DOI: 10.1016/j.bone.2004.01.001] [Citation(s) in RCA: 199] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2003] [Revised: 12/10/2003] [Accepted: 01/05/2004] [Indexed: 01/27/2023]
Abstract
The aim of the present study was to describe bone loss of the separate compartments of trabecular and cortical bone, as well as changes in bone geometry of a large number of spinal cord injured (SCI) individuals. Eighty-nine motor complete spinal cord injured men (24 tetraplegics and 65 paraplegics) with a duration of paralysis of between 2 months and 50 years were included in the study. Distal epiphyses and midshafts of the femur, tibia, and radius were measured by peripheral quantitative computed tomography. The same measurements were performed in a reference group of 21 healthy able-bodied men of the same age range. In the femur and tibia, bone mass, total and trabecular bone mineral density (BMDtot and BMDtrab, respectively) of the epiphyses, as well as bone mass and cortical cross-sectional area of the diaphyses, showed an exponential decrease with time after injury in the spinal cord injured subjects. The decreasing bone parameters reached new steady states after 3-8 years, depending on the parameter. Bone mass loss in the epiphyses was approximately 50% in the femur and 60% in the tibia, while the shafts lost only approximately 35% in the femur and 25% in the tibia. In the epiphyses, bone mass was lost by reducing BMD, while in the shaft bone mass was lost by reducing cortical wall thickness, a process achieved by endosteal resorption advancing at a rate of about 0.25 mm/year within the first 5-7 years after injury. Except for a slight transient decrease in cortical BMD of the femoral and tibial shaft during the first 5 years after the spinal cord lesion, cortical BMD of the spinal cord injured subjects was found to be at reference values. Bone parameters of the radial epiphysis in paraplegic subjects showed no deficits compared to the reference group. Furthermore, a trend for an increased radial shaft diameter suggests periosteal apposition as a consequence of increased loading of the arms.
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Affiliation(s)
- P Eser
- Institute for Clinical Research, Swiss Paraplegic Centre, 6207 Nottwil, Switzerland.
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Eser P, de Bruin ED, Telley I, Lechner HE, Knecht H, Stüssi E. Effect of electrical stimulation-induced cycling on bone mineral density in spinal cord-injured patients. Eur J Clin Invest 2003; 33:412-9. [PMID: 12713456 DOI: 10.1046/j.1365-2362.2003.01156.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Bone atrophy in spinal cord-injured people (SCI) is, among other factors, caused by immobilization and is initiated shortly after the injury. The present study measured the effect of an functional electrical stimulation (FES)-cycling intervention on bone mineral density (BMD) of the tibia in recently injured SCI people. METHODS As soon as possible after the injury (mean 4.5 weeks), para- and tetraplegic patients were recruited into an intervention and control group comparable with regard to gender, age, and lesion level. The intervention consisted of 30-min functional electrical stimulation-cycling three times a week for the duration of their primary rehabilitation (mean = 6 months). Computed tomography (CT) scans of the right tibia diaphysis were taken at the beginning and at the end of the intervention. Bone mineral density of cortical bone was calculated from the CT scans. RESULTS A total of 38 subjects (19 in each group) were included in the study. Both groups showed a reduction in tibial cortical BMD of 0-10% of initial values within 3-10 months. The mean decrease in BMD was 0.3% (+/- 0.6) per month in the intervention group and 0.7% (+/- 0.8) in the control group. This difference did not reach statistical significance. Decrease of BMD was linearly correlated to initial BMD and age in the pooled data of both groups; subjects who had a high initial BMD and/or were older lost more bone. In neither group was bone loss associated with duration of immobilization nor lesion level. CONCLUSIONS Functional electrical stimulation-cycling applied shortly after SCI did not significantly attenuate bone loss.
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Affiliation(s)
- P Eser
- Swiss Paraplegic Centre, Nottwil, Swiss Federal Institute of Technology, Schlieren, Switzerland.
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Abel R, Cerrel Bazo HA, Kluger PJ, Selmi F, Meiners T, Vaccaro A, Ditunno J, Gerner HJ. Management of degenerative changes and stenosis of the lumbar spinal canal secondary to cervical spinal cord injury. Spinal Cord 2003; 41:211-9. [PMID: 12669085 DOI: 10.1038/sj.sc.3101435] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We describe the case of a 47-year-old female who sustained a C5/6 fracture with C6 complete spinal cord injury 26 years ago. She presented with increased spasticity of the lower extremities, the abdominal wall and episodes of autonomic dysreflexia. Imaging of the spine revealed post-traumatic kyphosis at the level of the injury and degenerative changes of the lumbar spine with marked facet joint hypertrophy at the level of L4/5 causing severe spinal canal stenosis. Discussants of this case comment on the possible pathophysiological mechanisms causing autonomic dysreflexia, especially the development of degenerative changes, Charcot arthropathy and the role of tethering mechanisms. The diagnostic options and management approaches are also discussed.
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Affiliation(s)
- R Abel
- Orthopädische Universitätsklinik, Abteilung 2, Heidelberg, Germany
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Stein RB, Roetenberg D, Chong SL, James KB. A wheelchair modified for leg propulsion using voluntary activity or electrical stimulation. Med Eng Phys 2003; 25:11-9. [PMID: 12485782 DOI: 10.1016/s1350-4533(02)00116-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A commercially available wheelchair has been modified for propulsion by movements of the lower legs. The feet are attached securely to a foot rest that can rotate around the knee joint. Movement is generated either with residual voluntary activation of the quadriceps (knee extensor) and hamstring (knee flexor) muscles, or with electrical stimulation of these muscles, if voluntary control is absent. Either a chain or a lever can couple the movements through a gearbox to the wheel to propel the wheelchair forward. Control of a wheelchair with the legs is more efficient than using the arms and has the potential to increase the mobility and whole-body fitness of many wheelchair users, but there is considerable variability between subjects. To address this variability, we measured for individual subjects the passive properties of the legs and foot at rest (effective stiffness and viscosity), the length-tension (torque-angle) properties of the active muscle groups, as well as their force-velocity curve and their activation and fatigue rates. The measured values were then inserted into a model of the leg-propelled wheelchair. The purpose of this paper is to test whether the model could predict the performance of individual subjects accurately and could be used, for example, to optimize the speed of the wheelchair for a given subject.
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Affiliation(s)
- R B Stein
- Centre for Neuroscience, 513 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, Canada T6G 2S2.
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Jones LM, Legge M, Goulding A. Intensive exercise may preserve bone mass of the upper limbs in spinal cord injured males but does not retard demineralisation of the lower body. Spinal Cord 2002; 40:230-5. [PMID: 11987005 DOI: 10.1038/sj.sc.3101286] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Cross-sectional study comparing a group of active spinal cord injured (SCI) males carefully matched for age, height, and weight with active able-bodied male controls. OBJECTIVES To compare bone mass of the total body, upper and lower limbs, hip, and spine regions in active SCI and able-bodied individuals. SETTING Outpatient study undertaken in two centres in New Zealand. METHODS Dual energy X-ray absorptiometry (DEXA) scanning was used to determine bone mass. Questionnaires were used to ascertain total time spent in weekly physical activity for each individual. The criterion for entry into the study was regular participation in physical activity of more than 60 min per week, over and above that required for rehabilitation. RESULTS Seventeen SCI and their able-bodied controls met our required activity criterion. Bone mineral density (BMD) values of the total body and hip regions were significantly lower in the SCI group than in their controls (P=0.0001). Leg BMD and bone mineral content (BMC) were also significantly lower in the SCI group (P=0.0001). By contrast, lumbar spine BMD and arm BMD and BMC did not differ between the SCI and control groups. Arm BMD and BMC were greater (not significant) than the reference norms (LUNAR database) for both groups. CONCLUSION Intensive exercise regimens may contribute to preservation of arm bone mass in SCI males, but does not prevent demineralisation in the lower body.
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Affiliation(s)
- L M Jones
- The School of Physical Education, University of Otago, Dunedin, New Zealand
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Garland DE, Adkins RH, Stewart CA, Ashford R, Vigil D. Regional osteoporosis in women who have a complete spinal cord injury. J Bone Joint Surg Am 2001; 83:1195-200. [PMID: 11507128 DOI: 10.2106/00004623-200108000-00009] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Regional bone loss in patients who have a spinal cord injury has been evaluated in males. In addition, there have been reports on groups of patients of both genders who had an acute or chronic complete or incomplete spinal cord injury. Regional bone loss in females who have a complete spinal cord injury has not been reported, to our knowledge. METHODS In a study of thirty-one women who had a chronic, complete spinal cord injury, we assessed bone mineral density in relation to age, weight, and time since the injury. The results were compared with the bone mineral density in seventeen healthy, able-bodied women who had been age-matched by group (thirty years old and less, thirty-one to fifty years old, and more than fifty years old). Dual-energy x-ray absorptiometry was used to measure the bone mineral density of the lumbar spine, hip, and knee; Z-scores for the hip and spine were calculated. RESULTS The mean bone mineral density in the spine in the youngest, middle, and oldest spinal-cord-injury groups was 98%, 108%, and 115% of the densities in the respective age-matched control groups (p < 0.0001), and the mean bone mineral density in the oldest spinal-cord-injury group was equal to that in the youngest control group. This gain in bone mineral density in the spine was reflected by the spine Z-scores, as the mean score in the oldest injured group averaged more than one standard deviation above both the norm and the mean score in the control group. The mean loss of bone mineral density in the knee in the youngest, middle, and oldest spinal-cord-injury groups was 38%, 41%, and 47% compared with the densities in the corresponding control age-groups (p < 0.0001). Furthermore, the oldest injured group had a mean reduction of knee bone mineral density of 54% compared with the youngest control group. The mean loss of bone mineral density in the hips of the injured patients was 18%, 25%, and 25% compared with the densities in the control subjects in the respective age-groups (p < 0.0001). CONCLUSIONS The bone mineral density in the spine either was maintained or was increased in relation to the time since the injury. This finding is unlike that seen in healthy women, in whom bone mineral density decreases with age. The bone mineral density in the hips of the injured patients initially decreased approximately 25%; thereafter, the rate of loss was similar to that in the control group. The bone mineral density in the knees of the injured patients rapidly decreased 40% to 45% and then further decreased only minimally.
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Affiliation(s)
- D E Garland
- Neurotrauma Division, Rehabilitation Research and Training Center on Aging with Spinal Cord Injury, CA, USA
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Dauty M, Perrouin Verbe B, Maugars Y, Dubois C, Mathe JF. Supralesional and sublesional bone mineral density in spinal cord-injured patients. Bone 2000; 27:305-9. [PMID: 10913927 DOI: 10.1016/s8756-3282(00)00326-4] [Citation(s) in RCA: 185] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This study was performed to evaluate supra- and sublesional bone mineral density (BMD) in spinal cord-injured (SCI) patients after 1 year postinjury, and to correlate the BMD to the neurological level; to correlate the sublesional demineralization to functional parameters (duration postinjury, duration of the initial bedrest); and to assess the role of classic methods of prevention such as walking or standing. Thirty-one SCI patients, all male, were studied vs. 31 controls (age matched). The mean age of the population was 36 years (range 18-60 years). Eleven were tetraplegic and 20 were paraplegic. Twenty-six patients dysplayed a complete motor lesion. The BMD was measured by dual-photon absorptiometry on the lumbar spine and on the femoral neck, and the bone mineral content (BMC) on whole-body scans. Particular attention was paid to the distal femur and proximal tibia upper third. Blood samples and urine samples included phosphocalcic parameters, with determination of urinary hydroxyproline and deoxypyridinoline. SCI patients showed a decrease of sublesional BMD of 41% in comparison with controls. This loss of bone mass is higher at the distal femur (-52%) and proximal tibia (-70%), which are the most common sites of fracture. The degree of demineralization for the lumbar spine, the pelvis, and the lower limbs is independent of the neurological level. The duration of acute posttraumatic immobilization (mean 43.3 days) and the time postinjury increase the loss of bone mass for lower limbs (p = 0.04) and particularly for the proximal tibia (p = 0.02). The study of biomechanical stress (i.e., standing, walking, sitting) does not influence the sublesional BMC. This study underlines the major role of the neurological lesion on the decrease of sublesional BMC in SCI patients and the absence of influence of biomechanical stress.
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Affiliation(s)
- M Dauty
- Rehabilitation Department, Hôpital Saint Jacques, Nantes, France.
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Bélanger M, Stein RB, Wheeler GD, Gordon T, Leduc B. Electrical stimulation: can it increase muscle strength and reverse osteopenia in spinal cord injured individuals? Arch Phys Med Rehabil 2000; 81:1090-8. [PMID: 10943761 DOI: 10.1053/apmr.2000.7170] [Citation(s) in RCA: 218] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To study the extent to which atrophy of muscle and progressive weakening of the long bones after spinal cord injury (SCI) can be reversed by functional electrical stimulation (FES) and resistance training. DESIGN A within-subject, contralateral limb, and matching design. SETTING Research laboratories in university settings. PARTICIPANTS Fourteen patients with SCI (C5 to T5) and 14 control subjects volunteered for this study. INTERVENTIONS The left quadriceps were stimulated to contract against an isokinetic load (resisted) while the right quadriceps contracted against gravity (unresisted) for 1 hour a day, 5 days a week, for 24 weeks. MAIN OUTCOME MEASURES Bone mineral density (BMD) of the distal femur, proximal tibia, and mid-tibia obtained by dual energy x-ray absorptiometry, and torque (strength). RESULTS Initially, the BMD of SCI subjects was lower than that of controls. After training, the distal femur and proximal tibia had recovered nearly 30% of the bone lost, compared with the controls. There was no difference in the mid-tibia or between the sides at any level. There was a large strength gain, with the rate of increase being substantially greater on the resisted side. CONCLUSION Osteopenia of the distal femur and proximal tibia and the loss of strength of the quadriceps can be partly reversed by regular FES-assisted training.
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Affiliation(s)
- M Bélanger
- Département de Kinanthropologie, Université du Québec à Montréal, Canada
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de Bruin ED, Dietz V, Dambacher MA, Stüssi E. Longitudinal changes in bone in men with spinal cord injury. Clin Rehabil 2000; 14:145-52. [PMID: 10763791 DOI: 10.1191/026921500670532165] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Quantitative bone assessment today is primarily based on the analysis of bone mineral density (BMD). The geometric and structural properties of bone, which are important parameters for skeletal strength, are generally not considered in the routine clinical assessment of spinal cord injury-related osteopenia. OBJECTIVE To study changes in structural and geometric properties of tibia bone longitudinally by means of peripheral quantitative computerized tomography and a biomechanical test method (bone stiffness measurement device Swing) in 12 subjects with spinal cord injury. DESIGN Measurements were conducted in the 5th week and around the 104th week after the spinal cord injury in a university hospital. RESULTS Paired Student's t-tests showed a significant decrease in trabecular (p < 0.05) and cortical bone (p < 0.05), as well as a significant decrease in geometric properties of tibia bone (p < 0.05) within two years after the spinal cord injury. Phase velocity propagation changed in three subjects within two years following the spinal cord injury. CONCLUSIONS This study indicates that beside changes in tissue composition, changes in bone geometric indices and in structural properties occur in the lower extremity after a spinal cord injury. In the tibia, consideration of geometric and biomechanical parameters of bone combined with bone mineral density measurements could result in an improved screening for spinal cord injury-related osteopenia and the prediction of fracture risk in spinal cord injury.
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Affiliation(s)
- E D de Bruin
- Laboratory for Biomechanics, Department of Materials, ETH Zurich, Switzerland.
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McKinley WO, Jackson AB, Cardenas DD, DeVivo MJ. Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med Rehabil 1999; 80:1402-10. [PMID: 10569434 DOI: 10.1016/s0003-9993(99)90251-4] [Citation(s) in RCA: 374] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To analyze the incidence, risk factors, and trends of long-term secondary medical complications in individuals with traumatic spinal cord injury. DESIGN Data were reviewed from the National SCI Statistical Center on annual evaluations performed at 1, 2, 5, 10, 15, and 20 years after injury on patients injured between 1973 and 1998. SETTING Multicenter Regional SCI Model Systems. MAIN OUTCOME MEASURES Secondary medical complications at annual follow-up years, including pneumonia/atelectasis, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, and renal calculi. RESULTS Pressure ulcers were the most frequent secondary medical complications in all years, and individuals at significant (p < .05) risk included those with complete injuries (years 1, 2, 5, 10), younger age (year 2), concomitant pneumonia/atelectasis (year 1, 2, 5), and violent injury (years 1, 2, 5, 10). The incidence of pneumonia/atelectasis was 3.4% between rehabilitation discharge and year-1 follow-up with those most significantly at risk being older than 60 years (years 1, 2, 5, 10) and tetraplegia-complete (years 1, 2). One-year incidence of deep venous thrombosis was 2.1% with a significant decline seen at year 2 (1.2%), and individuals most significantly (p < .001) at risk were those with complete injuries (year 1). The incidence of calculi (kidney and/or ureter) was 1.5% at 1-year follow-up and 1.9% at 5 years and was more frequent in patients with complete tetraplegia. Intermittent catheterization was the most common method of bladder management among patients with paraplegia but became less common at later postinjury visits. CONCLUSIONS Pressure ulcers, autonomic dysreflexia, and pneumonia/atelectasis were the most common long-term secondary medical complications found at annual follow-ups. Risk factors included complete injury, tetraplegia, older age, concomitant illness, and violent injury.
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Affiliation(s)
- W O McKinley
- Department of Physical Medicine & Rehabilitation, Medical College of Virginia/Virginia Commonwealth University, Richmond 23298, USA
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Nance PW, Schryvers O, Leslie W, Ludwig S, Krahn J, Uebelhart D. Intravenous pamidronate attenuates bone density loss after acute spinal cord injury. Arch Phys Med Rehabil 1999; 80:243-51. [PMID: 10084430 DOI: 10.1016/s0003-9993(99)90133-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the effects of a 6-month treatment with intravenous pamidronate (30-mg infusion once per month) to conventional rehabilitation without pamidronate on bone density of the spine and leg bones and on the excretion rate of N-telopeptide, a urinary marker of bone catabolism, in acutely spinal cord injured patients. DESIGN A nonrandomized control trial in which 24 spinal cord injured subjects entered the study within 6 weeks of their injury. Fourteen subjects received pamidronate; 10 did not. OUTCOME MEASURES Bone density measurements by dual x-ray absorptiometry were performed before the initial treatment (within 6 weeks of the injury) and at 3, 6, and 12 months postinjury and was the primary efficacy parameter. Urine for N-telopeptide levels was the secondary efficacy parameter. RESULTS After acute spinal cord injury, patients treated with intravenous pamidronate had significantly less bone density loss compared with those who did not receive pamidronate (parametric ANOVA, p<.02). Also, ambulatory subjects had significantly less bone density loss over the study period (p<.05) than nonambulatory subjects. In general, a high excretion level of the urinary bone-breakdown product N-telopeptide was found before intravenous pamidronate treatment, followed by a dramatic reduction in excretion after pamidronate treatment. Ambulatory subjects excreted significantly less N-telopeptide than motor-complete subjects at all time points. CONCLUSION Intravenous pamidronate treatment and ambulatory ability in the first 6 months after an acute spinal cord injury prevents bone density loss.
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Affiliation(s)
- P W Nance
- Spinal Cord Research Centre, Health Sciences Centre, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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de Bruin ED, Frey-Rindova P, Herzog RE, Dietz V, Dambacher MA, Stüssi E. Changes of tibia bone properties after spinal cord injury: effects of early intervention. Arch Phys Med Rehabil 1999; 80:214-20. [PMID: 10025500 DOI: 10.1016/s0003-9993(99)90124-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of an early intervention program for attenuating bone mineral density loss after acute spinal cord injury (SCI) and to estimate the usefulness of a multimodality approach in diagnosing osteoporosis in SCI. DESIGN A single-case, experimental, multiple-baseline design. SETTING An SCI center in a university hospital. METHODS Early loading intervention with weight-bearing by standing and treadmill walking. PATIENTS Nineteen patients with acute SCI. OUTCOME MEASURES (1) Bone density by peripheral computed tomography and (2) flexural wave propagation velocity with a biomechanical testing method. RESULTS Analysis of the bone density data revealed a marked decrease of trabecular bone in the nonintervention subjects, whereas early mobilized subjects showed no or insignificant loss of trabecular bone. A significant change was observed in 3 of 10 subjects for maximal and minimal area moment of inertia. Measurements in 19 subjects 5 weeks postinjury revealed a significant correlation between the calculated bending stiffness of the tibia and the maximal and minimal area moment of inertia, respectively. CONCLUSION A controlled, single-case, experimental design can contribute to an efficient tracing of the natural history of bone mineral density and can provide relevant information concerning the efficacy of early loading intervention in SCI. The combination of bone density and structural analysis could, in the long term, provide improved fracture risk prediction in patients with SCI and a refined understanding of the bone remodeling processes during initial immobilization after injury.
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Affiliation(s)
- E D de Bruin
- Department of Material Sciences, Laboratory for Biomechanics ETH, Zurich, Switzerland
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Szollar SM, Martin EM, Sartoris DJ, Parthemore JG, Deftos LJ. Bone mineral density and indexes of bone metabolism in spinal cord injury. Am J Phys Med Rehabil 1998; 77:28-35. [PMID: 9482376 DOI: 10.1097/00002060-199801000-00005] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We evaluated the pattern of osteoporosis after spinal cord injury, determined the time-frame of the changes, and elucidated the relationship among parathyroid hormone levels, biochemical markers of bone formation, and the pattern of bone mass loss. We included 176 subjects with spinal cord injury and 62 subjects without spinal cord injury as controls in the study. Bone mineral density of the spine and the proximal femur was measured. The participants' age, level of injury, and length of time since injury were compared with the nonspinal cord-injured controls and with each other. Serum levels of calcium, calcitonin, biochemical markers of bone formation, and parathyroid hormone were determined. Our results revealed that bone mineral density of the proximal femur declined and reached fracture threshold at one to five years after injury. The decline was detected at 12 months after injury in all age groups. Spinal bone mineral density neither declined significantly nor reached fracture threshold. Parathyroid hormone levels declined before the end of the first year postinjury and increased at one to nine years postinjury in the 20- to 39-year age group. The increase correlated with the initial decline of bone mineral density of the proximal femur. Our studies in spinal cord-injured subjects revealed a pattern of osteoporosis similar to age and parathyroid dysfunction-related osteoporosis. No other correlation was detected between indexes of bone metabolism and bone mineral density measurements.
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Affiliation(s)
- S M Szollar
- Department of Orthopedic Rehabilitation, University of California, San Diego, USA
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